Provider Demographics
NPI:1417686361
Name:SMITH, MADISON VICTORIA (DMD)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:VICTORIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 E FORT UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3142
Mailing Address - Country:US
Mailing Address - Phone:801-943-2020
Mailing Address - Fax:
Practice Address - Street 1:2114 E FORT UNION BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-3142
Practice Address - Country:US
Practice Address - Phone:801-943-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT128742501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice